Acute suicidal affective disturbance: Factorial structure and initial validation across psychiatric outpatient and inpatient samples.

BACKGROUND: A new clinical entity, Acute Suicidal Affective Disturbance (ASAD), was recently proposed to characterize rapid-onset, acute suicidality including the cardinal symptom of behavioral intent. This study examines the proposed ASAD criteria factor-analytically and in relation to correlates of suicidal behavior and existing psychiatric disorders in samples of psychiatric outpatients and inpatients. METHODS: Two samples of psychiatric outpatients (N=343, aged 18-71 years, 60.6% female, 74.9% White) and inpatients (N=7,698, aged 15-99 years, 57.2% female, 87.8% White) completed measures of their ASAD symptoms and psychological functioning. RESULTS: Across both samples, results of a confirmatory factor analysis supported the unidimensional nature of the ASAD construct. Additionally, results provided evidence for the convergent and discriminant validity of ASAD, demonstrating its relation to, yet distinction from, other psychiatric disorders and correlates of suicide in expected ways. Importantly, ASAD symptoms differentiated multiple attempters, single attempters, and non-attempters, as well as attempters, ideators, and non-suicidal patients, and was an indicator of past suicide attempts above and beyond symptoms of depression and other psychiatric disorders. LIMITATIONS: This study utilized cross-sectional data and did not use a standardized measure of ASAD. CONCLUSIONS: ASAD criteria formed a unidimensional construct that was associated with suicide-related variables and other psychiatric disorders in expected ways. If supported by future research, ASAD may fill a gap in the current diagnostic classification system (DSM-5) by characterizing and predicting acute suicide risk.

How does active substance use at psychiatric admission impact suicide risk and hospital length-of-stay?

Despite their high prevalence, little is known about the effects of substance use disorders and active substance use on the suicide risk or length-of-stay of psychiatric inpatients. This study examines the relationship between active substance use at the time of psychiatric hospitalization and changes in suicide risk measures and length-of-stay. Admission and discharge ratings on the Suicide Status Form-II-R, diagnoses, and toxicology data from 2,333 unique psychiatric inpatients were examined. Data for patients using alcohol, tetrahydrocannabinol, methamphetamines, cocaine, benzodiazepines, opiates, barbiturates, phencyclidine, and multiple substances on admission were compared with data from 1,426 admissions without substance use. Patients with substance use by toxicology on admission had a 0.9 day shorter length-of-stay compared to toxicology-negative patients. During initial nurse evaluation on the inpatient unit, these patients reported lower suicide measures (i.e., suicidal ideation frequency, overall suicide risk, and wish-to-die). No significant between-group differences were seen at discharge. Patients admitted with a substance use disorder diagnosis had a 1.0 day shorter length-of-stay than those without, while those with a substance use disorder diagnosis and positive toxicology reported the lowest measures of suicidality on admission. These results remained independent of psychiatric diagnosis. For acute psychiatric inpatients, suicide risk is higher and length-of-stay is longer in patients with substance use disorders who are NOT acutely intoxicated compared with patients without a substance use disorder. Toxicology-positive patients are less suicidal on admission and improve faster than their toxicology-negative counterparts. This study gives support to the clinical observation that acutely intoxicated patients may stabilize quickly with regard to suicidal urges and need for inpatient care.

Time to Remission for Depression with Collaborative Care Management (CCM) in Primary Care.

BACKGROUND: Collaborative care management (CCM) has been shown to have superior outcomes to usual care (UC) for depressed patients with a fixed end point. This study was a survival analysis over time comparing CCM with UC using remission (9-item Patient Health Questionnaire [PHQ-9] score <5) and persistent depressive symptoms (PDSs; PHQ-9 score ≥10) as end points. METHODS: A retrospective cohort study of 7340 patients with depression cared for at 4 outpatient primary care clinics was conducted from March 2008 through June 2013. All adult patients diagnosed with depression (International Classification of Diseases, 9th Revision [ICD-9], codes 296.2-3) or dysthymia (ICD-9 code 300.4) with an initial PHQ-9 score ≥10 were included. CCM was implemented at all clinics between 2008 and 2010. Kaplan-Meyer survival curves for time to remission and PDSs were plotted. A Cox proportional hazards model was used to adjust for expected differences between patients choosing CCM versus UC. RESULTS: Median time to remission was 86 days (95% confidence interval [CI], 81-91 days) for the CCM group versus 614 days (95% CI, 565-692 days) for the UC group. Likewise, median duration of PDSs was 31 days (95% CI, 30-33 days) for the CCM group versus 154 days (95% CI, 138-182 days) for the UC group. In the Cox proportional hazards model, which controlled for covariates such as age, sex, race, diagnosis, and initial PHQ-9 score, CCM was associated with faster remission (hazard ratio of the CCM group [HRCCM], 2.48; 95% CI, 2.31-2.65). CONCLUSIONS: This study demonstrated that patients enrolled in CCM have a faster rate of remission and a shorter duration of PDSs than patients choosing UC.

CRAFFT as a Substance Use Screening Instrument for Adolescent Psychiatry Admissions.

BACKGROUND: Adolescent use of alcohol and illicit substances is quite common among pediatric psychiatry inpatients; however, little data exist on substance use screening instruments that can be used to augment thorough psychiatric diagnostic interviews. CRAFFT is a screening tool for adolescent substance use that has been validated in outpatient general medical settings. This is the first study to examine its use in adolescent psychiatric inpatients. METHODS: We performed a chart review of records from adolescents admitted to our inpatient psychiatric unit who completed a CRAFFT screen on admission. We compared CRAFFT scores with other measures of substance use, including urine drug screens and the diagnosis of a substance use disorder at discharge. We also examined measures of depression and suicidality in individuals with elevated CRAFFT scores (≥2 positive answers out of 6) and compared them with measures in those with normal CRAFFT scores. RESULTS: Elevated CRAFFT scores were correlated with other measures of alcohol and substance use, including the diagnosis of a substance use disorder at discharge (P<0.0001), and laboratory screening for alcohol (P=0.0048) and marijuana (P<0.0001) on admission. Previous suicide attempts (P=0.005) and "psychiatric trauma" (P=0.0027) were also positively associated with elevated CRAFFT scores. CONCLUSIONS: CRAFFT scores in adolescent inpatients were correlated with other measures of substance use, supporting its efficacy as a screening tool in this population. CRAFFT scores were also positively correlated with a history of psychiatric trauma and past suicide attempts, which is consistent with the results of previous studies associating pediatric substance use and traumatic life events with an increased risk of suicide.

Minority Primary Care Patients With Depression: Outcome Disparities Improve With Collaborative Care Management.

BACKGROUND/OBJECTIVES: Racial and ethnic disparities in depression incidence, prevalence, treatment, and outcomes still persist. The hypothesis of this study was that use of collaborative care management (CCM) in treating depressed primary care patients would decrease racial disparities in 6-month clinical outcomes compared with those patients treated with usual primary care (UC). RESEARCH DESIGN/SUBJECTS: In a retrospective chart review analysis, 3588 (51.2%) patients received UC and 3422 (48.8%) patients were enrolled in CCM. Logistic regression analyses were used to examine disparities in 6-month outcomes. RESULTS: Minority patients enrolled in CCM were more likely to be participating in depression care at 6 months than minority patients in UC (61.8% vs. 14.4%; P≤0.001). After adjustment for demographic and clinical covariates, this difference remained statistically significant (odds ratio=9.929; 95% CI, 6.539-15.077, P≤0.001).The 568 minority UC patients with 6-month follow-up PHQ-9 data demonstrated a much lower odds ratio of a PHQ-9 score of <5 (0.220; 95% CI, 0.085-0.570; P=0.002) and a much higher odds ratio of PHQ-9 score of ≥10 (3.068; 95% CI, 1.622-5.804; P<0.001) when compared with the white, non-Hispanic patients. In contrast, the 2329 patients treated with CCM, the odds ratio for a PHQ-9 score of <5 or ≥10 after 6 months, demonstrated no significance of minority status. CONCLUSIONS: Utilization of CCM for depression was associated with a significant reduction of the disparities for outcomes of compliance, remission, or persistence of depressive symptoms for minority patients with depression versus those treated with UC.

Gender differences in the association of agitation and suicide attempts among psychiatric inpatients.

OBJECTIVE: To determine if the relationship of agitation with suicide ideation and suicide attempts differed between men and women. METHOD: Self-reported severity of agitation and other suicide risk factors was obtained from 7698 consecutive patients during admission for inpatient psychiatric treatment during a 5-year period. RESULTS: Agitation was highest among men with a history of suicide attempts. Agitation was significantly associated with frequency of suicide ideation and history of suicide attempt, but the gender-by-suicide interaction was only significant as a predictor of suicide attempt history. For men, agitation was associated with significantly increased risk for suicide attempt, but for women, agitation was not associated with risk for suicide attempt history. Results were unchanged when analyses were repeated among the subgroup of patients with suicide ideation. CONCLUSIONS: Agitation is associated with history of suicide attempt among male but not female psychiatric inpatients. Agitation differentiates between those men who have only thought about suicide and those who have made suicide attempts.

Use of the Suicide Status Form-II to investigate correlates of suicide risk factors in psychiatrically hospitalized children and adolescents.

BACKGROUND: Suicide is the third leading cause of death in the United States for youth 12-17 years or age. Acute psychiatric hospitalization represents a clear worst point clinically and acute suicide risk is the most common reason for psychiatric admission. We sought to determine factors associated with differences in individual suicide risk assessment for children and adolescents during acute psychiatric admission. METHODS: Study participants were 1153 youth consecutively admitted to an inpatient psychiatry unit who completed a self-administered Suicide Status Form (SSF) within 24h of admission. Additional information on suicide risk factors was obtained through medical chart abstraction. RESULTS: Females reported significantly greater psychological pain, stress, hopelessness, and self-hate on the SSF and were significantly more likely to have made a suicide attempt just prior to the index hospital admission (OR=1.59, SE=0.29; CI=1.12-2.26), report a family history of suicide (OR=2.02, SE=0.33; CI=1.47-2.78), and had experienced a greater number of inpatient psychiatry admissions related to suicidal ideation (RR=1.33, SE=0.13; CI=1.10-1.61). High school aged youth and those with a primary diagnosis of depression displayed consistently elevated SSF scores and risk factors for suicide compared to comparison groups. LIMITATIONS: Diagnosis was determined through chart abstraction. Responses to access to firearm question had missing data for 46% of the total sample. CONCLUSIONS: Systematic administration of a suicide-specific measure at admission may help clinicians improve identification of suicide risk factors in youth in inpatient psychiatry settings.

Serial infusions of low-dose ketamine for major depression.

BACKGROUND: Single infusions of ketamine have been used successfully to achieve improvement in depressed patients. Side effects during the infusions have been common. It is not known whether serial infusions or lower infusion rates result in greater efficacy. METHODS: Ten depressed patients were treated with twice weekly ketamine infusions of ketamine 0.5 mg/kg administered over 100 min until either remission was achieved or four infusions were given. Side effects were assessed with the Young Mania Rating Scale (YMRS) and the Brief Psychiatric Rating Scale (BPRS). Patients were followed naturalistically at weekly intervals for four weeks after completion of the infusions. RESULTS: Five of 10 patients achieved remission status. There were no significant increases on the BPRS or YMRS. Two of the remitting patients sustained their improvement throughout the four week follow-up period. CONCLUSIONS: Ketamine infusions at a lower rate than previously reported have demonstrated similar efficacy and excellent tolerability and may be more practically available for routine clinical care. Serial ketamine infusions appear to be more effective than a single infusion. Further research to test relapse prevention strategies with continuation ketamine infusions is indicated.

Survey of sensitive information written in patient notes by psychiatry trainees.

OBJECTIVE: Allowing psychiatric patients access to their electronic medical record (EMR) may cause difficulty related to the sensitivity of the note content. The authors investigated whether notes written by psychiatry trainees were ready for release to patients. METHODS: Authors conducted a review of 128 PGY-3 to PGY-5 outpatient notes not explicitly marked as "highly confidential." One psychiatrist and one non-psychiatrist read each note from the patient's perspective. Reviewers assigned a score of 0-2 (0: No Concern; 1: Some Concern; 2: Major Concern) for each note. RESULTS: Eighty-nine notes (70%) were assessed as "No Concern" by both reviewers; 30 (23%) were of "Some Concern;" and 9 (7%) were of "Major Concern;" 92 (72%) were deemed of "No Concern" by a psychiatrist, as compared with 120 (94%) by the non-psychiatrist. CONCLUSIONS: Trainee EMR outpatient notes are not likely to cause major concerns for patients who read them. Psychiatrist-reviewers identified more concerns than non-psychiatrist-reviewers.

Suicide in the US Army.

Suicide in the US Army is a high-profile public health problem that is complex and poorly understood. Adding to the confusion surrounding Army suicide is the challenge of defining and understanding individuals/populations dying by suicide. Data from recent studies have led to a better understanding of risk factors for suicide that may be specifically associated with military service, including the impact of combat and deployment on increased rates of psychiatric illness in military personnel. The next steps involve applying these results to the development of empirically supported suicide prevention approaches specific to the military population. This special article provides an overview of suicide in the Army by synthesizing new information and providing clinical pearls based on research evidence.

The association between the Kessler 10 and suicidality: a cross-sectional analysis.

OBJECTIVE: The aims of this study were to test the psychometric properties of the Kessler 10 (K10) in a clinical setting and to investigate the utility of the K10 as a means for identifying suicidality. METHODS: One hundred forty-nine inpatients at an inpatient psychiatric hospital completed a battery of assessments during their inpatient hospital stay. Factor analysis provided information suggesting multiple factor loadings present within the K10. A series of t tests examined differences of group means between suicidal participants and a control group, whereas multiple regression models examined the correlation between the K10 and several suicide-specific assessments. MAIN RESULTS: The K10 seems to be composed of 2 primary factors (depression and anxiety) and differentiated suicidal and nonsuicidal inpatients and was associated with several measures related to suicidality. CONCLUSIONS: The observed results indicate that the K10 may be an effective screener to measure occult suicidality in a clinical setting.

A cross-sectional investigation of the suicidal spectrum: typologies of suicidality based on ambivalence about living and dying.

OBJECTIVE: The aim of this study was to determine the validity of assigning suicidal individuals into differing typologies of suicidality based on their reported wish to live and wish to die. METHODS: One hundred five inpatients who reported suicidal ideation in the previous 48 hours completed a battery of assessments during inpatient psychiatric hospitalization. An algorithm was used to assign participants into 1 of 3 typologies of suicide: wish to live, ambivalent, or wish to die. Discriminant function analysis and group classification were used to predict group membership, followed by multiple analysis of variance and follow-up contrasts to measure between-group differences. MAIN RESULTS: Group classification resulted in 76% accuracy for predicting typology of suicidality based on scores from suicide-specific measures. Self-perceived risk of suicide and hopelessness were the strongest variables at differentiating between the 3 groups. Patients in the wish to die typology were less likely to report having never made a suicide attempt. CONCLUSIONS: Creating typologies of suicidality may prove useful to clinicians seeking to better differentiate among suicidal patients within a limited period of assessment.

Practical suicide-risk management for the busy primary care physician.

Suicide is a public health problem and a leading cause of death. The number of people thinking seriously about suicide, making plans, and attempting suicide is surprisingly high. In total, primary care clinicians write more prescriptions for antidepressants than mental health clinicians and see patients more often in the month before their death by suicide. Treatment of depression by primary care physicians is improving, but opportunities remain in addressing suicide-related treatment variables. Collaborative care models for treating depression have the potential both to improve depression outcomes and decrease suicide risk. Alcohol use disorders and anxiety symptoms are important comorbid conditions to identify and treat. Management of suicide risk includes understanding the difference between risk factors and warning signs, developing a suicide risk assessment, and practically managing suicidal crises.

The base rates and factors associated with reported access to firearms in psychiatric inpatients.

OBJECTIVE: The aim of this study was to define whether specific patient demographic groups, diagnoses or other factors are associated with psychiatric inpatients reporting firearms access. METHODS: A retrospective medical records review study was conducted using information on access to firearms from electronic medical records for all patients 16 years and older admitted between July 2007 and May 2008 at the Mayo Clinic Psychiatric Hospital in Rochester, MN. Data were obtained only on patients providing authorization for record review. Data were analyzed using univariate and multivariate logistic regression analyses accounting for gender, diagnostic groups, comorbid substance use, history of suicide attempts and family history of suicide/suicide attempts. RESULTS: Seventy-four percent (1169/1580) of patients provided research authorization. The ratio of men to women was identical in both research and nonresearch authorization groups. There were 14.6% of inpatients who reported firearms access. In univariate analysis, men were more likely (P<.0001) to report access than women, and a history of previous suicide attempt(s) was associated with decreased access (P=.02). Multiple logistic regression analyses controlling for other factors found females and patients with history of previous suicide attempt(s) less likely to report access, while patients with a family history of suicide or suicide attempts reported increased firearms access. Diagnostic groups were not associated with access on univariate or multiple logistic regression analyses. CONCLUSIONS: Men and inpatients with a family history of suicide/suicide attempts were more likely to report firearms access. Clinicians should develop standardized systems of identification of firearms access and provide guidance on removal.

Brief report: why suicide? Perceptions of suicidal inpatients and reflections of clinical researchers.

Qualitatively oriented research (e.g., studies of suicide notes) has shed valuable light on the phenomenology of suicidal states. However, one draw back to this approach is that conclusions drawn from such data are inferential. In the current study, we took a more direct approach by having a sample of 52 suicidal inpatients provide written responses to the following query: Why suicide? A reliable coding system was developed that captured seven distinct response types to our prompt (i.e., suicide was seen as: the easy way out, a permanent solution, an escape from pain, the only option, self-oriented, related to hopelessness, and relationally-focused). In our discussion, we further reflect on these patient perceptions of suicide in terms of theory, research, and practice.

An investigation of emotional upset in suicide ideation.

The Suicide Upsetness Assessment (SUA) was used to measure the phenomenological experience of emotional upset during active states of suicidal ideation. Forty-nine inpatients with a history of suicide-related behaviors at a Midwestern inpatient psychiatric hospital completed a battery of assessments during their inpatient hospital stay. After reviewing theories regarding suicidality by the research team, 6 separate categories related to suicidal ideation were created, which were then subdivided into groups. Chi-Square and Fisher Exact Tests provided information regarding characteristics of emotional upset most often associated with such suicide-related behaviors as frequency and lethality of past attempts. Emotional upset is a heterogeneous construct in suicidal individuals, the properties of which may provide for a more thorough risk assessment.

Population-based prevalence of smoking in psychiatric inpatients: a focus on acute suicide risk and major diagnostic groups.

OBJECTIVE: The aim of the study was to define the extent of current and lifetime smoking by diagnostic groups and suicide risk as reason for admission in a geographically defined psychiatric inpatient cohort. DESIGN: The study used a population-based retrospective chart review. METHODS: Smoking status and discharge diagnoses for Olmsted County, Minnesota, inpatients aged 18 to 65 admitted for psychiatric hospitalization in 2004 and 2005 were abstracted from the electronic medical record. Diagnostic groups were compared to each other using chi(2) tests and Fisher exact test to analyze smoking status within the inpatient sample with significance defined as P